Client-Counselor Consent Form
In order for Patricia Jones, M.A. Pastoral Counselor to counsel with you as a client by Email, either by the Long Question or a Short Question Email, or by Telephone counseling sessions, you must agree to the following: By agreeing to and submitting this Client-Counselor Consent Form, you indicate that you understand and agree to the terms and conditions stated below.
1.) You agree that you are at least 18 years old.
2.) You agree that you have read the separate section on Confidentiality, below,
and you agree with the terms set out in that section.
3.) Are you seriously considering suicide?
If you answered " Yes " to the above question, then online and telephone counseling is not for you. Please call the National Suicide Hotline at 1-800-784-2433, your local Suicide Hotline, or call 911. You need to get help immediately. If you are in a crisis state of wanting to take your own life, you should call the Suicide Hotline immediately. There are people there who care about you and who will offer you immediate assistance and help.
Confidentiality In General:
You understand and agree that as a Pastoral Counselor, I protect the confidentiality of the communications and contacts with all of my clients, including online and telephone clients. I will only release information about our work to others with your written permission except in the following situations:
a.) If I learn while we are working together that a child, elderly person, or disabled person is being abused, I am required to notify appropriate protective services. ( If you are an abused woman I will keep that completely confidential and it will be left up to you as to whether you want to notify the authorities, or go to a shelter for abused women, or leave your abuser. I will not let your abuser know that you have contacted me.)
b.) I am required to do so by a court order or legal subpoena.
c.) If you tell me while we are working together that you are considering committing suicide, committing serious self-injurious behavior or considering violence towards another person, I am required to notify the appropriate authorities.
3. ) I agree that I am responsible for my own life.
The goal of our online or telephone counseling is to help you. Therefore, if either of us feels, at any time, that working together is not helpful enough to you; either of us is free to terminate our relationship at any time. There are no other explicit or implicit commitments in our relationship.
